Early supported discharge: getting adolescents back on track
Authors: George C Patton
Journal: The Lancet Psychiatry (2018)

Mental disorders have been characterised as the chronic diseases of the young.1Insel TR Fenton WS Psychiatric epidemiology: it's not just about counting anymore.Arch Gen Psychiatry. 2005; 62: 590-592Crossref PubMed Scopus (119) Google Scholar Many emerge in late childhood and adolescence with consequences for mental health and individual potential in later life and for the next generation.2Rodwell L Romaniuk H Nilsen W Carlin JB Lee K Patton GC Adolescent mental health and behavioural predictors of being NEET: a prospective study of young adults not in employment, education, or training.Psychol Med. 2018; 48: 861-871Crossref PubMed Scopus (60) Google Scholar, 3Patton GC Olsson CA Skirbekk V et al.Adolescence and the next generation.Nature. 2018; 554: 458Crossref PubMed Scopus (184) Google Scholar The early age of onset has driven interest in adolescent intervention.4McGorry PD Hickie IB Yung AR Pantelis C Jackson HJ Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions.Aust N Z J Psychiatry. 2006; 40: 616-622Crossref PubMed Scopus (0) Google Scholar Yet, despite growing policy attention to adolescent mental health services, secular trends show little sign of diminishing prevalence, and in some places rates might be rising.5Collishaw S Annual research review: secular trends in child and adolescent mental health.J Child Psychol Psychiatry. 2015; 56: 370-393Crossref PubMed Scopus (346) Google Scholar, 6Mojtabai R Olfson M Han B National trends in the prevalence and treatment of depression in adolescents and young adults.Pediatrics. 2016; 138: e20161878Crossref PubMed Scopus (747) Google Scholar Persisting high unmet need for treatment in many places and failure to deliver effective treatments for most adolescents who reach health care are signs that service systems are faltering.6Mojtabai R Olfson M Han B National trends in the prevalence and treatment of depression in adolescents and young adults.Pediatrics. 2016; 138: e20161878Crossref PubMed Scopus (747) Google Scholar Even where major investments have been made to improve access to health care for adolescents and young adults, the gains for those who do receive care seem small with little apparent shift of disorder prevalence in the community.7Hilferty F Cassells R Muir K et al.Is headspace making a difference to young people's lives? Final report of the independent evaluation of the headspace program. Social Policy Centre, UNSW, Sydney2015Google Scholar, 8Jorm AF Patten SB Brugha TS Mojtabai R Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries.World Psychiatry. 2017; 16: 90-99Crossref PubMed Scopus (262) Google Scholar There are various reasons for these sobering trends: inadequate understanding and response to major social determinants of mental health that lie outside the health care system; a lag in investment benefits due to long-term neglect of adolescents by health services; and a shortage of empirical research to guide policy and practice. Poor adaptation of mental health actions to the unique developmental context of adolescence is probably another consideration. Interventions that work in younger children and adults are commonly less effective in adolescents, partly because of differences in the ways adolescents engage.9Yeager DS Dahl RE Dweck CS Why interventions to influence adolescent behavior often fail but could succeed.Perspect Psychol Sci. 2017; 13: 101-122Crossref PubMed Scopus (160) Google Scholar They shape their social environment much more than younger children, including encounters with the health care system, with engagement likely to be positive where the system is sensitive to the developmental tasks of the individual. In this context, Dennis Ougrin and colleagues10Ougrin D Corrigall R Poole J et al.Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychatric emergencies: a randomised controlled trial.Lancet Psychiatry. 2018; (published online May 3.)http://dx.doi.org/10.1016/S2215-0366(18)30129-9Summary Full Text Full Text PDF Scopus (48) Google Scholar present a refreshing trial in The Lancet Psychiatry in which they assess an early supported discharge service (SDS) as an alternative to traditional care in an inpatient unit. Extended inpatient care can disrupt relationships that are essential for positive development, including those with family, school, peers, the community, and workplaces. A service system that allows the re-establishment of these connections at an early point is intuitively appealing. The SDS package, which was tailored to individual needs, provided a flexible mixture of psychotherapeutic approaches and focused on re-engagement with families, school, and peers. Outcomes were assessed in terms of hospital use and changes in scores on the Strengths and Difficulties Questionnaire and the Children's Global Assessment Scale (CGAS). Cost-effectiveness based on CGAS scores and quality-adjusted life-years (QALYs) was also measured. The SDS was associated with significantly reduced hospital use compared with usual care (median inpatient hospital days 34, IQR 17–63 vs 50, 17–125, p=0·04). The probability of SDS being cost-effective compared with usual care was around 58% when assessed with CGAS scores and around 60% when assessed with QALYs. The secondary outcomes of multiple self-harm episodes and reintegration into school showed substantial differences between groups. The odds ratio of patients in the SDS group reporting multiple episodes of self-harm was 0·18 (95% CI 0·05–0·64, p=0·008), and for reintegration into a community school by 6 months was 4·14 (1·73–9·92, p=0·001). Given that the SDS was designed to provide an alternative to inpatient care, the reductions in hospital use are perhaps unsurprising. However, the positive shifts in self-harm and reintegration into school at 6 months of follow-up are striking, as is the finding that this approach is likely to be a cost-effective alternative to usual inpatient care.10Ougrin D Corrigall R Poole J et al.Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychatric emergencies: a randomised controlled trial.Lancet Psychiatry. 2018; (published online May 3.)http://dx.doi.org/10.1016/S2215-0366(18)30129-9Summary Full Text Full Text PDF Scopus (48) Google Scholar Boege and colleagues' findings in a study in Germany11Boege I Corpus N Schepker R Kilian R Fegert J Cost-effectiveness of intensive home treatment enhanced by inpatient treatment elements in child and adolescent psychiatry in Germany: a randomised trial.Eur Psychiatry. 2015; 30: 583-589Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar complement the those of Ougrin and colleagues. These data together strengthen the view that well resourced health services adapted to the developmental needs of adolescents might not only be a cost-effective alternative to traditional care but, ultimately, could also produce better life outcomes for adolescents after mental health crises.11Boege I Corpus N Schepker R Kilian R Fegert J Cost-effectiveness of intensive home treatment enhanced by inpatient treatment elements in child and adolescent psychiatry in Germany: a randomised trial.Eur Psychiatry. 2015; 30: 583-589Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Nevertheless, pressing questions remain for the research community. The studies by Ougrin and colleagues and Boege and colleagues are small with quite short follow-up.10Ougrin D Corrigall R Poole J et al.Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychatric emergencies: a randomised controlled trial.Lancet Psychiatry. 2018; (published online May 3.)http://dx.doi.org/10.1016/S2215-0366(18)30129-9Summary Full Text Full Text PDF Scopus (48) Google Scholar, 11Boege I Corpus N Schepker R Kilian R Fegert J Cost-effectiveness of intensive home treatment enhanced by inpatient treatment elements in child and adolescent psychiatry in Germany: a randomised trial.Eur Psychiatry. 2015; 30: 583-589Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar Adolescents have high rates of spontaneous short-term symptom remission and, therefore, it is unsurprising that these trials have shown small differences in symptoms between treatment and comparison groups. Longer-term follow-up is needed to assess whether benefits of early interventions are sustained for disorders that might relapse and recur over the course of decades. Determining whether a brief intervention or whether continued engagement with service systems is better to achieve medium-term clinical and developmental outcomes is a priority. Furthermore, understanding about who will benefit from more intensive and systematic early interventions needs to be improved. Some studies have suggested that most adolescents will experience some form of mental or behavioural disorder, but for many these will not persist into adulthood. Beyond the short-term persistence of symptoms, prognostic factors should be clarified to increase the efficient targeting of health care.12Patton GC Coffey C Romaniuk H et al.The prognosis of common mental disorders in adolescents: a 14-year prospective cohort study.Lancet. 2014; 383: 1404-1411Summary Full Text Full Text PDF PubMed Scopus (310) Google Scholar Expanding effective mental health service systems for adolescents is now a pressing global health priority. Understanding adolescent developmental needs will be a cornerstone of any strategy. Easy accessibility, staff well trained in communication, and the willingness to engage with adolescents as active partners in health care decisions will be essential. Gaining a better grasp of prognostic factors for what might become chronic and relapsing disorders will help to direct interventions.4McGorry PD Hickie IB Yung AR Pantelis C Jackson HJ Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions.Aust N Z J Psychiatry. 2006; 40: 616-622Crossref PubMed Scopus (0) Google Scholar Lastly, ensuring that health service actions support young patients in re-establishing relationships outside hospital that are disrupted by mental health crises will be essential. To assess the benefits of responsive mental health care for adolescents effectively, trials will need to be bigger, last longer, and include life outcomes beyond symptoms. Researchers and funders need to think differently about treatments that are becoming the dominant chronic disorders among young people, and must view adolescence as providing a foundation for mental health throughout life. I declare no competing interests. Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trialSDS provided by an intensive community treatment team reduced bed usage at 6 months' follow-up but had no effect on functional status and symptoms of mental health disorders compared with usual care. The possibility of preventing admissions, particularly through features such as reduced self-harm and improved reintegration into school, with intensive community treatment should be investigated in future studies. Full-Text PDF Open Access