Navigating stormy seas: European perspectives on the transition from child to adult mental health care for depressed and suicidal young people

Although existing research has yielded important insights into the transition
from CAMHS to AMHS, several key questions remain unaddressed. Most studies
rely on retrospective designs, small samples, or clinical records, and rarely
incorporate the perspectives of young people or their families. In addition,
research has been conducted primarily in English-speaking countries such as
the United Kingdom, the United States, and Australia, raising questions about
the generalisability of findings to broader contexts. The MILESTONE project
was developed to expand scientific knowledge on the transition from child to
adult mental healthcare (Singh et al., 2017; Tuomainen et al., 2018).
Although major depressive disorder and suicidal ideation are highly prevalent
and significantly influence help-seeking behaviour among young people, the
transition to adult mental health care for this group remains an underexplored
area in current research. This is particularly striking given that several wellestablished
risk factors are associated with the persistence of major depressive
disorders into adulthood. For the purpose of this thesis, these will be referred
to as risk factors for persistent depression, and include: early onset of
depression (before age 21), peer and family relationship difficulties, parental
psychopathology, greater functional impairment, and more severe mental
health symptoms, such as suicidality and comorbid psychiatric conditions
(notably anxiety, personality, and substance use disorders) (Hankin & Griffith, 2023; Holzel et al., 2011; Lereya et al., 2015; Schraeder & Reid, 2017). Despite this
increased knowledge on the continuation of major depressive disorders into
adulthood, these studies did not account for service use, did not distinguish
between CAMHS and AMHS use nor take into account the transition young
people had to make. Research on continuity of care does suggest that young
people with emotional disorders, especially depression, are less likely to be
referred to AMHS, and even when referred, many ultimately rejected (Islam
et al., 2016; Singh et al., 2010). These findings raise important questions:
“Which factors influence clinicians’ decisions when recommending continued
treatment for depressed and suicidal young people?” and “Do these transition
processes differ from those of CAMHS users with other types of mental health
concerns?”. Chapter 2 explores whether clinicians incorporate established risk
factors for persistent depression into their transition recommendations, and
whether these differ from factors associated with CAMHS users in general.
Understanding these factors may help clinicians better identify those most
at risk and improve transition recommendations accordingly.
Discrepancies between self-reported and clinician-reported symptoms may
hinder the accurate identification of at-risk youth and complicate transition
decisions, especially in youth reporting internalising problems including
symptoms of depression and suicidality. Prior results from the MILESTONE
study indicated that neither self- nor parent-reported emotional or behavioural
problems, including suicidal ideation, influence clinicians’ transition
recommendations (Gerritsen et al., 2022). Chapter 3 therefore investigates
the impact of these potential informant discrepancies further and examines
how they relate to transition recommendations and mental health service use
at 9-month follow-up.
As no studies to date have evaluated long-term mental health outcomes of
young people who transition to AMHS versus those who do not (Appleton
et al., 2019), part two of this thesis presents the first longitudinal analyses
to assess both mental health outcomes and service use among young
people reaching the upper age limit of their CAMHS. Chapter 4 provides a
comprehensive overview of the care pathways of young people with a broad
range of mental health problems who are reaching the upper age limit of their
CAMHS, identifies predictors of these pathways and examines their association
with mental health outcomes over a two-year follow-up period. Chapter 5
focuses specifically on young people with depressive symptoms, tracking
their symptom progression during the transition to adulthood, identifying
those whose symptoms persist or worsen, and evaluating whether they receive
appropriate mental health care. It also explores whether these individuals may
require a distinct transition process compared to CAMHS users in general. The third part of this thesis delves into the experiences of young people and
their parents with the transition from CAMHS to AMHS. Chapter 6 responds to
the lack of standardised tools for evaluating the transition experiences in young
mental health care by introducing and validating a user-friendly instrument
for assessing transition experiences quantitatively. Chapter 7 complements
this with a qualitative exploration of young people’s and parents’ narratives,
highlighting the emotional and practical aspects of the transition process and
identifying perceived facilitators and barriers.
In the concluding chapter, Chapter 8, the main findings are summarised
and discussed in the context of the current literature. Methodological
considerations are addressed, and implications for clinical practice and
recommendations for future research are presented.